The Department of Industrial Relations and its Division of Workers’ Compensation posted a progress report on the department’s Independent Medical Review (IMR) program.
IMR is the medical dispute resolution process that uses medical expertise to obtain consistent, evidence-based decisions and is one of the most important components of Senate Bill 863, Governor Edmund G. Brown Jr.’s landmark 2012 workers’ compensation reform.
“This shows that Independent Medical Review – which replaced a system where injured workers had to wait for medical treatment while disputes were litigated – continues to provide a timely, efficient process for resolving treatment disputes and supporting appropriate care,” said George Parisotto, DWC Administrative Director.
Maximus Federal Services has been the Independent Medical Review Organization (IMRO) since the program’s inception in 2013 and is under contract to provide IMR through 2019.
In 2017, the IMRO processed 248,251 applications, a slight decrease from 2016. Concurrently, the IMRO issued 172,194 IMR determinations.
At the end of 2016, the average length of time the IMRO took to issue a determination, after the receipt of all necessary medical records, was 15 days. By mid-2017, this decreased to a monthly average of 11 days.
Overall, the IMRO overturned 8.3% of the utilization review decisions that denied treatment requests made by physicians treating injured workers.
Analysis of several variables, including the geographic region of the injured worker, the time elapsed since the worker’s work-related injury occurred, and representation by an attorney or other entity acting on behalf of the injured worker, shows similar rates of overturned case decisions.
As in the previous three calendar years, requests for pharmaceuticals in 2017 comprised nearly half (42.6%) the issues in dispute, with opioids the most common drug class (29.3%). Diagnostic tests, including radiology, imaging, and pathology, were the second-most-requested treatment category (16.2%).
Rehabilitation services – such as physical therapy, chiropractic, and acupuncture – were the third-most-requested category (14.1%).
The treatment category most often overturned was evaluation and management (with a 16.3% overturn rate), which includes specialist consultations and dental services, followed by behavioral and mental health services, which had an overturn rate of 16.3%.
Enhancements that may aid the IMR program continued in 2017. Updates to the Medical Treatment Utilization Schedule (MTUS) included several updated and new chapters as well as the adoption of a formulary. The Division of Workers’ Compensation (DWC) introduced its second online Physician Education Module.
Today’s report, as well as previous reports on IMR data, are posted on DWC’s IMR webpage under IMR program updates